Analysis Passenger Loading and Vessel Freeboard The vessel was outfitted with seating and life-saving equipment for 12passengers; however, the operator had no formal instruction or other guidance regarding its maximum safe carrying capacity. At the time of the occurrence, 16passengers and their effects were embarked, and their combined weight/distribution caused both pontoons to become deeply immersed. Although the total weight of passengers and the freeboard of the pontoons were neither monitored nor recorded on departure, based on the number of persons carried, the deadweight exceeded that employed in the simulated loading condition with 12passengers. The simulation showed that, even when so loaded, the vessel retained markedly less reserve buoyancy than that called for by accepted design practice. Consequently, the greater number and weight of passengers on board at the time of the occurrence would have exacerbated the situation. At the time of the occurrence, the total weight of the passengers and their effects caused both pontoons to become deeply immersed, leaving insufficient freeboard and reserve buoyancy for safe navigation. The low freeboard was such that the forward ends of the pontoons became completely submerged by the bow waves generated by the vessel's forward motion. This caused the sudden increase in forward trim and the downward plunge of the bow. The marked forward trim was subsequently reduced by a reduction of speed and the repositioning of passengers toward the after end of the vessel. Vessel Inspection by Transport Canada As the Wascana Centre Authority (WCA) senior management lacked marine expertise, a request was made to Transport Canada Marine Safety (TCMS) for guidance on regulatory requirements pertaining to the operation, construction, inspection, and certification of both vessels and crews. In response to the requests, TCMS forwarded excerpts from the relevant Canada Shipping Act regulations. No one from TCMS visited the vessels. The regulations are complex and the excerpts lacked specific guidance to the WCA. The absence of such guidance was compounded by the fact that SSB nos.11/99 and 04/2001 had not been sent to the WCA and were unknown to them. Consequently, the non-conformity with the regulatory requirements which affected the safe operation of the vessel, went unnoticed until the occurrence. Dissemination of Safety Information In the past, safety information (i.e., SSBs) was disseminated to stakeholders by way of an established mailing list. However, in recent years, SSBs are also posted on the internet.4 Whereas anyone may request being placed on the mailing list, not everyone who operates a small vessel is aware of its existence. A review of the SSB mailing list, maintained by TCMS, showed that a substantially large number of small vessel operators, including the WCA, are not on the list. In response to TSB Marine Safety Advisory No.07/01, TCMS has recognized that the current method of disseminating safety information is not always effective. Consequently, an evaluation of the system is under way to determine the most effective method of communicating relevant safety information to specific audiences.5 In this instance, although the WCA had sought previous guidance from TCMS on regulatory matters, the WCA was not on the TCMS SSB distribution mailing list for small passenger vessels. Complexity of Regulatory Safety Requirements Regulatory compliance for small passenger vessels of 15gross tons and under is based on self-enforcement by owners. The application of the self-enforcement principle presupposes that the owner has in-depth knowledge of marine legislation and the operational environment, and has sufficient resources and appropriate skills to educate the operator or crew. This principle may work well in large corporations; however, few operations within the small vessel sector engaged in carrying passengers, fishing activity, or other commercial activity have a scale of operation sufficiently large to allocate resources to meet these objectives. The majority of the over 30000small vessels operating in Canada are operated by small companies or individuals who may own and operate a vessel with a few employees. There is no requirement for the owner to possess in-depth knowledge of marine regulations or for the operator to possess academic qualifications, nor is a competency test required before a person can engage in marine activities. The complexity of regulations is such that they are not readily understood by those persons who must apply them. Simplifying regulations in the small vessel industry is crucial to support self-enforcement. This need has been recognized by TCMS, which, in other marine sectors, has published guides and manuals to assist owners or operators operate their vessels safely.6 There is no such publication for the small passenger vessel sector. The difficulty in interpreting current complex marine legislation calls into question the practicality of self-enforcement as a compliance tool for small vessels. The issue of self-enforcement of complex legislation and regulations has been discussed in the 1996TSB report on an occurrence involving the S.S.Brothers (TSBReportNo.M96M0144). The Board recommended that legislation be presented in a manner readily understood by those to whom it applies.7 While the recommendation addressed provincial labour legislation as it applies to fishing vessel safety, the principle equally applies to any legislation that uses self-enforcement as a means of enforcement. Standard Operating Procedures, Training, and Safety The lack of formal SOPs governing WCA marine activities provided personnel with little or no practical knowledge on operating the vessel and fostered an environment in which unsafe practices can go undetected. As the vessel is engaged in carrying passengers, among other requirements, operators ought to be knowledgeable in the safe navigation of the vessel; passenger safety including departure and arrival briefings; basic information such as the effect of weight distribution on vessel stability; and safety and emergency procedures. In this instance, no such training had been given to the operator. This could account for the operator's action during the emergency, which resulted in no safety action or instructions being provided to the passengers. Given the various applications for which small passenger vessels are used, it is essential that the training given to the crew take into consideration any special needs of the clientele serviced by the vessel. Emerging Trends and Safety It is estimated that 3.8million Canadians 15years of age and over have a disability, some 440000of whom travelled by ferry in 1995.8 As the population ages, and as the incidence of disability increases with age, the number of persons with disabilities using marine transportation will increase. Given that: governments and the transportation and travel industries are placing more emphasis on catering to the needs of persons with disabilities, continuous efforts are made to integrate persons with disabilities into society, and educational and recreational activities enjoyed by the general public may also affect the health and well-being of persons with disabilities, it is essential that safety requirements, by way of equipment or training, be considered to enhance the safety of persons with disabilities using marine means of transportation, whether for recreation or essential travel. Current regulations applicable to commercial operations do not provide the flexibility that would help address the issue of the safety of persons with disabilities. Operator Certification and Safety A minimum level of skill and knowledge is required of those who operate an automobile or aircraft, be it for commercial or recreational purposes. However, in the marine environment, there is no such proficiency/competency requirement for operators of small commercial vessels, whether used for carrying passengers, fishing activities, or other commercial operations.9 A proficiency requirement is extended to some pleasure craft operators, which will eventually apply to all operators by September2009.10 The need for formal training of operators of vessels has been recognized by TC as well as by the Canadian Coast Guard. Crewing Regulations for commercial vessels and the Competency of Operators of Pleasure Craft Regulations are intended to address this need. Nevertheless, operators of small vessels, such as passenger vessels of 15gross tons or less that do not carry more than 12passengers and fishing vessels 60gross tons and under, are not required to demonstrate a minimum level of knowledge to operate their vessels. As a result, many small commercial vessel operators continue to operate in Canadian waters without demonstrating a minimum knowledge. Generally, these operators have a limited knowledge of vessel operation, including passenger safety. Further, no criteria or guidelines have been established by TCMS for training in these matters. The Board is concerned that the absence of a proficiency requirement increases the chances for marine accidents and unnecessarily exposes crews and passengers to risk. Consequently, the Board recommended that TC develop training standards and certification requirements for the operators of small vessels.11 In a recent TSB report, involving the TrueNorthII, the Board reiterated its concern that shortcomings in the evaluation and certification processes may result in operators with inadequate competency to operate vessels, thereby placing crews and passengers at undue risk. In response, TC has undertaken several initiatives to address this concern: since June2000, the oral examination for limited certificates includes an evaluation based on the vessel and its area of operation; the written and oral examinations cover core competencies in navigational safety (i.e., rules of the road), stability, meteorology, navigation, ship construction, and other operational requirements; substantial work has been done on this issue; a standard method of recording oral examination questions and results in the Automated Certification Examination System has been developed; continuing competency to be demonstrated every five years by personnel holding limited certificates ; and updating The Examination and Certification of Seafarers, TP2293, to reflect changes to the national syllabus (Revision02 was completed on 24September2002). TC has initiated action to address competency issues for operators of vessels. However, these provisions have not been extended to all commercial vessels (such as small passenger vessels 5 gross tons and under carrying not more than 12passengers, small commercial vessels 10gross tons or less and small fishing vessels 60 gross tons or less). Therefore, crews and/or passengers on these vessels will continue to be subject to undue risk. The risk had been identified in TSB ReportNo.M93L0003 (Tan1) and RecommendationM96-01, however this issue is still not addressed. In this regard, it should be noted that operators of pleasure craft are required to meet proficiency standards. Regulatory Regime and Safety In an aging population, the number of passengers with disabilities, some of whom cannot wear any form of restraint, is increasing. This precludes them from using the standard lifejackets that vessels are required to carry. There is a need for flexibility in the regulations, so that different operations can provide life-saving equipment appropriate to the risks associated with those operations. This has been recognized by TC and is reflected in the Board of Steamship Inspection Decision No.6587, which allows persons on board vessels engaged in whale-watching to wear full-length PFD in lieu of the carriage requirement of approved standard lifejackets, provided that the suits are worn by passengers and crew for the duration of the trip. However, the current requirement for small vessels to carry personal life-saving equipment , whether the vessel is carrying passengers or engaged in fishing or other commercial operations, does not reflect the flexibility accorded to the whale-watching industry. Regulations do not permit the carriage of personal life-saving equipment that is best suited (based on risk exposure) to provide for a maximum period of survival to persons in the water. While risk-based methodology is used by TC to address safety deficiencies, the regulations in their current form do not yet reflect this reality. Current standards for life-saving equipment, based on specific design and manufacturing criteria, is prescriptive and consequently restricts the manufacturing process. A risk-based approach to life-saving equipment standards would give the manufacturer the flexibility to tailor the product to meet the varying needs of the marine sector and provide an acceptable minimum level of safety. Such an approach would also allow for continuous improvements in life-saving equipment design due to technological progress and can potentially raise the threshold of safety. The combined weight of the operator, three wheelchairs, 16passengers and their effects resulted in both pontoons being nearly submerged, leaving insufficient freeboard and reserve buoyancy for safe navigation. The forward ends of the pontoons became completely submerged by the bow waves generated by the vessel's forward motion, causing the loss of reserve buoyancy, and the sudden trim and downward plunge of the bow. No formal instruction or training was provided to the operator on the safe loading and operation of the vessel. She was not certificated nor was there a requirement for an operator of a small commercial vessel such as the WascaII to formally demonstrate proficiency or competency by passing a Transport Canada (TC) examination and obtaining a certificate of competency.Findings as to Causes and Contributing Factors The combined weight of the operator, three wheelchairs, 16passengers and their effects resulted in both pontoons being nearly submerged, leaving insufficient freeboard and reserve buoyancy for safe navigation. The forward ends of the pontoons became completely submerged by the bow waves generated by the vessel's forward motion, causing the loss of reserve buoyancy, and the sudden trim and downward plunge of the bow. No formal instruction or training was provided to the operator on the safe loading and operation of the vessel. She was not certificated nor was there a requirement for an operator of a small commercial vessel such as the WascaII to formally demonstrate proficiency or competency by passing a Transport Canada (TC) examination and obtaining a certificate of competency. Procedures adopted by TC for disseminating safety-related information are not always effective; vital safety advice and directives are not always conveyed to owners or operators. The self-enforcement of safety measures to ensure regulatory compliance is ineffective in some sectors of the industry because of the lack of awareness, the complexity of regulations and the lack of experience of some owners in interpreting them. Personal life-saving equipment on board the vessel included non-approved lifejackets, and there were not enough personal flotation devices (PFD) for the number of persons on board. Current regulations do not permit or consider the carriage of personal life-saving equipment, which is best suited (based on risk exposure) to provide maximum survival capability for persons in the water.Findings as to Risk Procedures adopted by TC for disseminating safety-related information are not always effective; vital safety advice and directives are not always conveyed to owners or operators. The self-enforcement of safety measures to ensure regulatory compliance is ineffective in some sectors of the industry because of the lack of awareness, the complexity of regulations and the lack of experience of some owners in interpreting them. Personal life-saving equipment on board the vessel included non-approved lifejackets, and there were not enough personal flotation devices (PFD) for the number of persons on board. Current regulations do not permit or consider the carriage of personal life-saving equipment, which is best suited (based on risk exposure) to provide maximum survival capability for persons in the water. At the time of the occurrence, there was no means of ship/shore communication on board the vessel. A previous similar occurrence was not reported to authorities, no investigation was carried out to determine cause, and no remedial action was taken to prevent a re-occurrence.Other Findings At the time of the occurrence, there was no means of ship/shore communication on board the vessel. A previous similar occurrence was not reported to authorities, no investigation was carried out to determine cause, and no remedial action was taken to prevent a re-occurrence. Safety Action Action Taken Vessel Taken out of Service The WascaII was taken out of service by the owners immediately after the incident pending investigation. On 19 June 2001, Transport Canada Marine Safety (TCMS) issued a detention order the WascaI and the WascaII until the identified deficiencies were rectified. Certification of Operators Four operators were tested for a Master Limited certificate of competency by TC, and all were successful in obtaining the certification. The operators are medically fit and have been trained in first aid and fire safety. At the May 2002 meeting of the Canadian Marine Advisory Council (CMAC), TCMS introduced a discussion paper titled Amendments to the Crewing Regulations and Marine Certification Regulations outlining proposals for new training and certification programs for the operators of small commercial and fishing vessels, including passenger vessels under 5gross tons. The paper proposes that the Crewing Regulations be amended to reflect that any commercial vessel, regardless of tonnage, be required to have a certificated master. It is reported that the proposal met with support from industry stakeholders attending the conference. Action Taken by the Wascana Centre Authority Following the occurrence, and under instructions from TCMS, the Wascana Centre Authority (WCA) has initiated the following action to enhance safety: The WCA has brought the vessels WascaI and WascaII into compliance with regulatory requirements. The void spaces were filled with marine styrofoam for positive buoyancy to the satisfaction of a TCMS inspector. TCMS inspected both vessels (WascaI and WascaII) in May2002 and cleared them for service. TCMS issued the WCA a commercial licence on 29June2001, and the WascaII was given a commercial licence number(co2585sk). The number of passengers on the WascaII will be limited to eight plus an operator for a total complement not to exceed nine persons. When freight (i.e., barbecues, picnic coolers, etc.) is carried, this weight will be taken into consideration, and the passenger limit will be reduced accordingly. The WCA has implemented the following policy with respect to passengers in wheelchairs: - the number of wheelchairs has been limited to three per trip; - the wheelchair must be secured on the vessel; - passengers in wheelchairs must don a lifejacket prior to embarking; and - the weight of the wheelchair will be taken into account for load limits. The WCA will have vessel plans approved by TCMS prior to purchasing a vessel. Action Taken by TC An amendment to the Ship Station (Radio) Regulations1999, which will require all passenger vessels to be equipped with communications equipment, is expected to be completed in2003. Safety Concern Ship Safety Bulletins The distribution of Ship Safety Bulletins (SSB) is intended to provide vessel owners and operators with information and guidance on operational, regulatory and safety matters. However, the current system of distributing SSBs does not always reach target audiences. This problem was identified by the TSB following the sinking of the F/V Nadine and F/V CapeAspy12, at which time the Board recommended that: The Department of Transport evaluate the effectiveness of its distribution practices for all marine safety information aimed at fishing masters and fishermen. (M93-02, issued June 1993) TC accepted the recommendation and subsequently issued special SSBs in1993, 1995, 1996and1999 to advertise all post-1977/SSBs and solicit new subscribers. However, at the May2001 CMAC Standing Committee on Fishing Vessel Safety, fishing industry representatives stated that communications with fishermen was a huge problem and many indicated that they are not getting bulletins. For a vessel operator to receive SSBs, they must request that they be added to the TCMS distribution list, or have access to the TCMS website. As a result, only those that are aware that SSBs exist may receive and benefit from the information they convey. Evaluation of SSB distribution information provided by TCMS in mid-2001 indicates that, notwithstanding a population of at least 8800013 commercial vessels operating in Canada, only 334SSBs14 are distributed directly to shipowners and operators. For example, the province of Manitoba, which incorporates Lake Winnipeg, with over 1000commercial fishing vessels, receives only 11English copies of SSBs. In a Marine Safety Advisory (MSA07/01) sent to TCMS in2001, further concern was raised that the method of communicating safety information chosen by TC in the past was not appropriate for the groups targeted, as the SSBs have very limited distribution among small boat operators. In response, TCMS indicated that they also were concerned that the method of SSB communication was perhaps not the most effective for the intended target groups, and that a re-evaluation was under way to determine the best methods of getting relevant safety information to target groups that would benefit most from it. Models for the efficient distribution of safety information do exist within TC. For example, within the Transport Canada Aviation Safety branch, statutory safety information of a technical nature that requires immediate attention is sent directly to each registered aircraft owner affected through Airworthiness Directives. Such direct targeting of stakeholders is only possible when detailed records of registration are available, and the Board notes that TCMS does not currently possess an accurate database of Canadian commercial vessels. Staff continue to note occurrences, including this one, in which vessel operators are either not familiar with SSBs, or are unaware of how to access them. The Board, therefore, remains concerned that the SSB program used by TCMS for disseminating safety-related information continues to be less than effective in conveying vital safety advice and directives to owners and operators of commercial vessels. Operator Competency Regardless of the size of vessel, passengers and crew have an expectation that the operator is competent to conduct the vessel to a safe arrival at its destination. Following two accidents15 involving the small passenger vessel Tan1 in1993, the Board noted an increasing number of small passenger vessel sightseeing operations carrying fare-paying passengers. Believing that it is important for the safety of those fare-paying passengers that the operators of those vessels have formal marine training, the Board subsequently recommended that: The Department of Transport develop training standards and certification requirements for the operators of small sightseeing boats that carry fare-paying passengers. (M96-01, issued July 1996) In response, TC agreed with the recommendation and indicated that, with industry, it would develop a national standard for small passenger vessels and charter boats of less than 150gross tons. In a subsequent occurrence16 in1995, the utility vessel Showboat, carrying 33passengers and 6crew, sank close to the dock at Ontario Place, Toronto. In a Marine Safety Advisory (MSA03/96) sent to TCMS in1996, further concern was raised that, inter alia, the crew of the Showboat did not have formal marine training or certification. Since that time, TCMS has taken initiative in proposing new training and certification programs for the operators of small commercial and fishing vessels, including passenger vessels under 5grosstons. At the May 2002 CMAC meeting, TCMS introduced a discussion paper, Amendments to the Crewing Regulations and Marine Certification Regulations. The paper proposes that the Crewing Regulations be amended to reflect that any commercial vessel, regardless of tonnage, be required to have a certificated master. The Board notes, and is encouraged by, these recent program initiatives undertaken by TCMS and believes that, if effectively implemented, such initiatives could be an important element in affording the travelling public a proper level of safety regardless of vessel size or the number of passengers carried. Consequently, the Board will closely monitor the progress of the regulatory amendments.